5900-383 PE Verification Form

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OMB Control No. 2060-0347

ppendix 3: PE Verification Checklist

Plant: ____________________________________________________________________

Date: ________________

PE: ______________________________________________________________________

Review location: ___ Corporate Office ___ Site Visit

Plant Physical Characteristics and Eligibility

• The plant has established a formal certification file. Yes___ No___ If so, where? _____________________________

• The plant’s activities conform to the eligibility description in the EPI Instructions. Yes___ No___

• These plant activities are described in the certification file. Yes___ No___

• Relevant calculations of plant activities (e.g., space requirements) meet specified minimums in the EPI Instructions. Yes___ No___

• These plant calculations supporting eligibility are documented in the certification file. Yes___ No___

Plant Operating Characteristics

• All data are confirmed to belong to the plant named in the EPI and plant certification documents. Yes___ No___

• All data are confirmed to match the same 12-month time period specified on the Statement of Energy Performance. Yes___ No___

• The plant’s data is current (defined as within 4 months of the Period Ending Date on the Statement of Energy Performance). Yes___ No___

• All original source data (e.g., production records) has been reviewed to assure all data were correctly transcribed into a spreadsheet, database, etc. Yes___ No___

• If original source data are not available for review, it can be verified that appropriate internal verification procedures are applied to any company databases used for applicable data. Yes___ No___

• All calculations made using the original source data have been reviewed to assure accuracy, correct conversion of units, and use of generally accepted and uniformly applied conversion factors. Yes___ No___

• Annual totals resulting from all calculations match the values entered into the EPI. Yes___ No___

• Annual totals resulting from all calculations match the units specified in the EPI. Yes___ No___

• Inputs or calculations for other required plant physical characteristics (e.g., square footage, kilns) are consistent with source documents provided in the certification file. Yes___ No___

• All source data, calculations, and assumptions have been documented in the formal certification file. Yes___ No___

Note that referral to a company database is not adequate; the file must include a static record of data drawn from the database on the date of EPI completion (i.e., the date the EPI score and Statement of Energy Performance were produced).

• All production metrics (e.g., quantities, capacities, labor hours) follow the procedure specified in the EPI instructions. Yes___ No___

• Source data, calculations, and documentation for all other data types (e.g. HDD/CDD) have been reviewed and documented in the formal certification file. Yes___ No___

Energy Data

• All data confirmed to belong to the plant are named in the EPI and plant certification documents. Yes___ No___

• All data confirmed to match the same 12-month time period are specified on the Statement of Energy Performance. Yes___ No___

• The plant’s data are current (defined as within 4 months of the Period Ending Date on the Statement of Energy Performance. Yes___ No___

• All original source data (e.g., utility invoices) have been reviewed to assure all data were correctly transcribed into a spreadsheet, database, etc. Yes___ No___

• If original source data are not available for review, it can be verified that appropriate internal verification procedures are applied to any company databases used for applicable data. Yes___ No___

• All calculations made using the original source data have been reviewed to assure accuracy, correct conversion of units, and use of generally accepted and uniformly applied conversion factors. Yes___ No___

• Annual totals resulting from all calculations match the values entered into the EPI. Yes___ No___

• All source data, calculations, and assumptions have been documented in the formal certification file. Yes___ No___

Note that referral to a company database is not adequate; the file must include a static record of data drawn from the database on the date of EPI completion (i.e., the date the EPI score and Statement of Energy Performance were produced).

• Annual totals resulting from all calculations match the units specified in the EPI. Yes___ No___

• All energy sources used at the plant are included in the EPI. Yes___ No___

• All energy sources follow the energy accounting procedure specified in the EPI instructions. Yes___ No___

• Calculations for energy transfers (purchased steam, compressed air) have been reviewed for accuracy. Yes___ No___

ENERGY STAR Energy Performance Score

• All the required data have been entered into the EPI. Yes___ No___

• The data have been properly entered into the EPI. Yes___ No___

• The plant’s EPI score is 75 or higher. Yes___ No___

PE Verification

• The PE review of the plant has been documented (e.g., site visit vs. corporate office, date, personnel met with, findings/corrections/recommendations from the review). Yes___ No___

• The PE completed the Verification Checklist for submission to EPA, and added the original document to the formal certification file. Yes___ No___

• The PE signed, stamped – indicating if embossed, and provided the required license information on the Statement of Energy Performance for submission to EPA, and added the original document to the formal certification file. Yes___ No___

Please note any company personnel involved in review:

Please note any findings, corrections, or recommendations from the review:

The public reporting and recordkeeping burden for this collection of information is estimated to average 25 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form No. 5900-383